Simpler, Easier and Better Spine CareBrian Justice, DC Medical Director Excellus BlueCross BlueShield

Spine Health

High cost and high frustration.

Gateway to opioids, chronic diseases and better health!

Back and neck pain are not diseases in search of a cure, but normal conditions of

life that need to be managed.

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Source: New England Health Care Institute

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Information outpaces implementation

17 years Average time for research evidence to reach clinical practice.1

182 studies

Number of unique studies used to update the American College of Physicians Non-invasive Guidelines for Low Back Pain 2007 -2017.2

1. Balas (2000). Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics

2. Qaseem (2017) American College of Physicians Clinical Guideline. Annals of Internal Medicine

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Purpose

• Reduce the spine burden on the Primary Care Physicians by offering a “simpler, easier and better spine care pathway”

– Improve the value of spine services

– Ensure appropriate spine services at appropriate times

– Improve the quality of life for spine pain patients while decreasing inappropriate care

– Save PCP time/resources

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The problems of back pain

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Learning to become comfortable with uncertainty

• Rash of opioid use, fusion surgery for DJD examples of our difficulty with uncertainty

• Failure of pathoanatomical model to define LBP

• LBP may be more of an impairment in coping and this is primary problem to address

Simpkin A, et al NEJM 2016

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Themes

• Spine pain is a bio-psycho-social condition

• Language of the provider(s) is critical with spine pain patients

• Passive care either supports or is a catalyst to active care with spine pain

• Simplicity

• Support with best evidence (CDC,AHRQ,ACP,MCMS..)

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Spine Costs – Suffering and Dollars

• Low Back Pain lifetime prevalence – 84%

• 15% of patients have “severe disability”

• #1 cause of physical disability in United States and Internationally (WHO)

• World data – indirect costs 3-5 times direct costs

• Costs greater than ½ trillion dollars nationally

• Spine costs billions in Upstate New York

• 5% of patients account for 75% of the costs

Frymoyer JW, Cats-Baril WL. An overview of the

incidences and cost of low back pain

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What is the Intervention Really Worth?-3

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Ave

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Months Before and After Baseline Intervention

Average Cost Accumulation Per Patient By Intervention

Conservative Fusion Non-Fusion

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Evidence vs. Practice Patterns(University of Pittsburgh Study)

Mafi JN, et al JAMA Intern Med 2013

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Baseline State of Spinal Pain Care

© 2015 A. Milstein/Stanford

Univ7

Care Pathways Create Efficiencies

Pathway support

• Access

• Incentives

• Communications

EvidenceTechnologyDataPatients

Less Variation

Higher Quality

Lower Cost

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Communication is key

Hey!Hay?

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From parts to people

From pathoanatomical/reductionist to

biopsychosocial / holistic

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Emerging Spine Concepts

• From pathoanatomical to biopsychosocial model

• From anatomical problem to whole person experience

• From a focus on pain to a focus on function / life

• Pain has emotional and cognitive components

• Chronic pain involves CNS dysfunction

• Treatment must focus on the whole person, not just the area of pain

• Recognize irrelevant abnormalities (imaging)

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Filling the Gaps

• Innovation: optimizing workforce, guideline to pathway

• Value solution to simultaneously meet the needs of:

– Patients (whom do they like, trust? Incentives?)

– Providers (how do they communicate? Incentives?)

– Employers (indirect costs 2-5 times direct costs)

– Payer (simple, operational, non-disruptive)

– Community (public health initiative)

• Creating High Performing Networks and Teams (change behavior

without disruption)

• Creating foundation for value based reimbursement / shared risk /

shared reward

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‘First Touch’ Data

Conservative Spine Care: Opportunities to Improve the Quality and Value of Care

Thomas M. Kosloff, DC,1 David Elton, DC,2 Stephanie A. Shulman, DVM, MPH,3

Janice L. Clarke, RN,4 Alexis Skoufalos, EdD,4 and Amanda Solis, MS4

POPULATION HEALTH MANAGEMENT

Volume 0, Number 0, 2013

Which treatments or advice were helpful?

Based on a nationally representative Consumer Reports survey of back-pain suffers who said they had consulted with the

professional for advice or treatment.

Yoga or Tai Chi Instructor 89%

Massage Therapist 84%

Chiropractor 83%

Physical Therapist 75%

Neurosurgeon 67%

Acupuncturist 66%

Orthopedist or Orthopedic Surgeon 65%

Primary Care Doctor 64%

Rheumatologist 61%

Consumer Reports, June 2017

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Quality Through ‘Front End Efficiencies’

• Efficient Delivery Systems

– Pathway-Trained Practitioner can be the “Hub of the Wheel”

– “Feeder” Referral Pathways from ED, UC, PCPs, Medical Home, ACOs, Employer Groups

– Standardize evaluation and management across provider groups and clinical settings (minimize variation)

– Partnerships with high performing specialists across multiple disciplines: spine surgeons, pain specialists, neurology, mental health, PMR/physiatry

• Public Education Campaign – self triage (ED?), self care, prevention, “stay a person” (Hadler)

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CMS has called for a “refitting” of the existing workforce.

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The Excellus BlueCross BlueShield Spine Health Program

• Program Evolution (2009 . . . )

– Beth-Israel Deaconess

Hospital

– Spine Care Partners, LLC

Care pathway

• Provider training

– Licensing agreement with

SCP and hired dedicated

medical director Oct. 2012

– Vetted and published

• Program Principles

– Simple Solutions

• Re-redefine spine pain

• Engage patients

• Biopsychosocial model

• First touch, low tech

• “Less is more”

Back and neck pain are not diseases in search of a cure,

but normal conditions of life that need to be managed

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Pathway + Trained Providers = Value

• Cross discipline evidence / reviewed locally / process driven /

patient-centered

• Value = benefits (patient, community) / costs (episode, indirect)

• Quick information / evidence dissemination / data collection

• Providers bring individual patient context to pathway

– Meaningful shared decision making

– Motivational interviewing

– Psychosocial screening

– Minimize fear provoking language (DDD)

– Patient preference matters

The Excellus BlueCross BlueShield Spine Health Program

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• ‘First Touch’ Providers – Pathway training

(500+ exposed to date)

– Primary Care Practitioners (1-2 CME’s)

– Primary Spine Practitioners (24-100

CME’s)

– Decrease variation, improve

communication

• Early risk identification

– 5% spine patients account for 75% of

cost; risk stratification (StarT Back)

– Functional loss / psychosocial screen

(PROMIS?)

– Appropriate care early, triggers

significant savings downstream (direct

and indirect costs)

• Patient engagement (active, shared)

• Provider value quotient (benefit/cost)

• Culture change, aligning incentives

– Employers

– Hospitals, ACOs, providers

– Patients and communities

– Payers

The Excellus BlueCross BlueShield Spine Health Program

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Pathway that…

• Defines simple 'first touch'principles that minimize development of chronic disability

• Evaluates for rare instances of serious pathology

• Minimizes unnecessary testing

• Helps define roles among practitioners that are more condition/patient based and less based on broad specialist care

• Allows for coordination of patients bridging primary care/emergency care to specialty care

• Allows for specificity in treatment and referral based on agreed upon heterogeneous clinical presentation

• Identifies patients at high risk for long term chronic disabling pain reliably and efficiently and allows this to effectively influence management strategies

Does all of this cost effectively with VALUE in mind

Pathway Training Themes

• Spine pain is a bio-psycho-social condition

• Language of the provider(s) is critical with spine pain patients

• Shift from a focus on pain to a focus on function / life

• Passive care either supports or is a catalyst to active care with spine pain

• Simplicity

• Support with best evidence (CDC,AHRQ,ACP,MCMS..)

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Mind-bending themes

• Stop calling it ‘Back Pain’

✓ The label triggers patient and provider focus

✓ Pain focus leads to passive (Rx) care

✓ Hypervigilent to treating the pain

• Primary objective in treating an acute spine related disorder is to prevent chronicity

✓ Triggers self-care / active-care discussion

✓ Needs a biopsychosocial construct

✓ Focus on management and quality of life

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Right Patient Right Provider

Right Time

• History Taking

• Examination

• Imaging

• Treatment

• Examples

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Referring PCP Spine Algorithm

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Pathway Training Survey Results

Questionstrongly disagree

mildly disagree

neutralmildly agree

strongly agree

% of agree responses

The material presented strongly supported the course objective(s). 4 11 100%

The material was presented in an organized, easily assimilated manner. 1 3 11 93%

The instructor's teaching style was interesting and facilitated learning of the material. 1 1 2 11 87%

The instructor presented relevant material that I can begin using in my office on Monday morning. 1 1 13 87%

Survey of 15 participants in April 2018

training at Bassett Healthcare

Expectations Influence Recovery

Continuation of Activity

Pain confrontation

Active copingSelf-

efficacy

Activity Disengagement

Pain experience

CatastrophizingFear-

avoidance

Depression

Negative Expectation

Cycle

PositiveExpectation

Cycle

Modified Fear avoidance model(Vlaeyen & Linton, 2000)

Self-efficacy model(Bandura, 1977)

Slide used with permission from: Sherri Weiser NYU School of Medicine

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Risk Factors for Chronicity

• Previous history of low back pain

• Total work loss (due to low back pain) in past twelve months

• Radiating leg pain

• Reduced straight leg raising

• Signs of nerve root involvement

• Reduced trunk muscle strength and endurance

• Poor physical fitness

• Self-rated health poor

• Heavy smoking

• Psychological distress and depressive symptoms

• Disproportionate illness behavior

• Low job satisfaction

• Personal problems - alcohol, marital, financial

• Adversarial medico-legal proceedings

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StarT Back 9-item Questionnaire

• Disability (function)

• Catastrophizing

• Fear (anxiety)

• Depression

• Risk of Chronicity

• Function

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Cultivating Change Talk

• Explore the patient’s own ambivalence

• Have the patient explore challenges and benefits; pros and cons

• Encourage self-efficacy

• Over 200 RCTs on MI *exclusion of populations which bias results

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3 Minute Exam: Focus on Neuro

• Look, Touch, Move, Ask

• Motor Screen

• Deep Tendon Reflex

• Sensory Screen (situational)

• Nerve Tension Screen

• Upper Motor Screen (upper extremity and lower extremity if neck or upper ext.)

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Imaging Findings of Questionable Clinical Significance

• Disc bulge

• Disc degeneration

• Disc signal loss

• Disc dessication

• Spondylosis

• Facet arthrosis

• Arthritis

“Iatrogenic Imaging Disability”

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Choosing Wisely

Don’t do imaging for low back pain within the first six weeks, unless red flags are present.

Or

Don’t obtain imaging studies in patients with non-specific low back pain.

• American Academy of Family Physicians

• American College of Physicians

• American College of Occupational & Environmental Medicine

• North American Spine Society

• American Association of Neurological Surgeons

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Imaging may trigger worse outcomes

• Randomized controlled trial:

- plain film imaging for back pain versus no imaging

- MRI for back pain versus no imaging.

• Results - The group receiving imaging had:

- no better outcomes

- scored lower on self-perceived health status - - demonstrated a higher likelihood of persistent pain - - utilized higher number of office visits Chou R, Deyo Imaging strategies for low back pain: systematic review and meta analysis

Kendrick, Radiography of the lumbar spine in primary care patients with low back pain: randomized controlled trial. BMJ 2001

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Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related Disabling - Low Back Pain SPINE Vol 38 , Num 22 , 2013

Objective:

• To determine the effect of early (receipt < 30 d post onset) magnetic resonance

imaging (MRI) on disability and medical cost outcomes

Results:

• 37% of the nonspecific LBP and 80% of the radiculopathy cases received early MRI. The early-MRI groups had similar outcomes regardless of radiculopathy status: more disability, on average $13,000 higher medical costs than the no-MRI groups.

Conclusion:

• Early MRI without indication has a strong iatrogenic effect in acute LBP, regardless of radiculopathy status. Providers and patients should be made aware than when early MRI is not indicated, it provides no benefits, and worse

outcomes are likely.

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Age-specific prevalence estimates of degenerative spine imaging finding in asymptomatic patients

Age (yr)

Imaging Finding 20 30 40 50 60 70 80

Disk degeneration 37% 52% 68% 80% 88% 93% 96%

Disk bulge 30% 40% 50% 60% 69% 77% 84%

Disk protrusion 29% 31% 33% 36% 38% 40% 43%

Facet degeneration 4% 9% 18% 32% 50% 69% 83%

Spondylolisthesis 3% 5% 8% 14% 23% 35% 50%

Brinjikji, Deyo, et al AJNR 2014

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Lumbar MR Imaging and Reporting Epidemiology: Do Epidemiologic Data in Reports Affect Clinical Management? McCullough,Radiology: March 2012

Imaging needs context

“More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms”

Patient misconceptions concerning lumbar spondylosis diagnosis and treatment, Franz, Neurosurg Spine 2015

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DEGENERATIVE SKIN DISEASE!

DEGENERATIVE HAIR DISEASE!

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Language

“Words are, of course, the most powerful drug used by mankind”

- Rudyard KiplingRoyal College of Surgeons, 1923

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The Enduring Impact of What Clinicians Say to People With Low Back Pain – Darlow, An Fam Med Nov 2013

• Information and advice received at consultation can continue to influence patient beliefs for many years

• Identify messages that may be interpreted negatively and instill the confidence to deliver positive messages instead

• Clear activity advice and appropriate reassurancecan be empowering

• Packaging information and advice that enables people to use their back freely, potentially reducing the persistence of disability

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Setting the Stage - What you say often has more impact than what you do –

• Severe pain does NOT indicate a catastrophic event

• Very rarely does spine pain truly need emergent care

• Important to get the patient to relax with their pain.

(Increased anxiety/fear creates more perceived pain)

• Use positive language re: expectation for recovery

• Keep it simple when possible: activity, heat/ice, OTCs

• Manage, not cure

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Adopting a Helpful Lexicon

• Avoid complicated/complex medical terminology when possible.

• Verbalize that you have ruled out any underlying serious pathology.

• Be calm, confident, positive and empathetic.

– Physician attitudes and beliefs correlate with patient attitudes and beliefs and therefore clinical outcomes.

• Encourage staying active and that their pain does NOT mean they are doing more damage.

– Pain Neuroscience Education

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Bio medically-Based Communication

What you say: What the patient hears:

Your MRI shows degenerative changes/disc herniation/arthritis

I will never get better

There’s nothing wrong with your back

He/she thinks It’s all in my head

Stop when you feel pain Activity will harm my back

Take it easy and rest I should stay in bed

If chiropractic or physical therapy doesn’t work you may need surgery

I will need surgery

You should be able to work He/she thinks I am faking

Pain is normal for someone your age

I’m going to get worse

Slide used with permission from: Sherri Weiser NYU School of Medicine

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Psychologically-Based Communication

What you say What the patient hears

Your MRI doesn’t show anything to worry about

There is nothing seriously wrong with my back

The cause of your pain may not show up on an MRI

My pain is real

You should increase activity as tolerated

Activity is good for me

Your back problem should respond to chiropractic or physical therapy

I probably won’t need surgery

Working will not cause damage to your back

I will be able to return to work

There are many things you can do on your own to control your pain

I can learn to handle my pain

Slide used with permission from: Sherri Weiser NYU School of Medicine

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ACP Guideline for acute, subacute, chronic LBP

Annals Int Med 2017, Qaseem A, et al

Recommendation #1

• Given that most patients with acute or sub acute low back pain improve over time regardless of treatment, clinicians and patients should select non-pharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select non-steroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence).

(Grade: strong recommendation)

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Shift from Passive to Active Care

• ACP

• CDC

• AHRQ

• JACHO

• NIH

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Mindful practice– Being “present” serves both the patient (demonstrates

caring) and the physician (provides meaning to clinical practice)

– In a typical PCP office visit the physician interrupts the patient within 18 seconds of asking a question

– Physicians are trained/driven to explain, fix, advise when listening and empathizing may help the patient more (60% of patients misunderstood directions after an office visit with the PCP)

Verghese, A. Health Affairs 2016

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Back Pain linked to psychological disorders

– What is perpetuating this pain and suffering experience?

– Acute and chronic back pain are linked to

• Depression

• Psychosis

• Anxiety

• Stress

• Sleep disorders

Stubbs B, General Hospital Psychiatry 2016

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What is perpetuating this pain and suffering experience?

The “Psych Big 5”

• Fear

• Catastrophizing

• Passive Coping

• Poor self-efficacy

• Depression

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The Neuro matrix(Melzak R. Pain 1999; S6:121-126)

A combination of centers in the brain that act together in producing the pain experience.

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Nervous System Sensitization

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The good and bad of Neuroplasticity

…. “neurons that fire together, wire together”

Our brain loves patterns

Emotions, touch, sight, smell…can all trigger or amplify a pain experience

….or lessen a suffering experience

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The Role of Beliefs in Chronic Spinal Pain(Main CJ, Watson PJ. Man Ther 1999; 4(4):203-215)

• Patient experiences pain, then...

• Patient forms a belief (judgment) about the pain, then...

• Patient forms an emotional response based on this belief, then...

• Patient engages in behavior consistent with this belief and emotional response

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Challenges: Chronic Pain is “Biopsychosocial”

• Attitudes and Beliefs

• Distress and Depression

• Illness Behavior

• Social Environment

Psychological

Pain Not Simple Linear System

• Peripheral Sensitization

• Central Sensitisation

Physiological

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Seeking Pain Relief Increases Pain!!Attempts to control pain prioritize attention towards signals of pain: an experimental study. Notebaert, Pain 2011

Seeking relief of pain in lieu of improved function actually increases pain by facilitative hypervigilance for pain.

YOU MUST TAKE AN ACTIVE ROLE IN TREATING YOUR PAIN!

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Heightened Pain Response

• Nonorganic signs : distraction and simulation are best

– raise the leg up to check the ankle reflex, later do a SLR and tell the patient “I want you to tell me if this hurts”.

– standing rotation test : rotate the trunk as a unit and ask if it hurts

– non anatomical distribution of pain to light touch

RTW? - provide a work note for a couple of days and tell them “if you are still not sure if you can return at that point, you need to see a PSP or occ med group”.

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Medications………….opiates

(Passive care only to catalyze active care)

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Common pain conditions that are almost never indicated for opioids

• Fibromyalgia

• Headache

• Self-limited illness, i.e., sore throat

• Uncomplicated back and neck pain

• Uncomplicated musculoskeletal pain

Institute for Clinical Systems Improvement.

Acute Pain Assessment and Opioid Prescribing Protocol. Jan 2014

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Scientific Evidence ?

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The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic PainAgency for Healthcare Research and Quality (AHRQ) Feb 2016

• >4200 studies

• No study evaluated effects of long-term opioid therapy versus no opioid therapy

Noninvasive Treatments for Low Back Pain

• Strong opioids verses placebo: “ The clinical magnitude of effects was small, typically equivalent to about 1 point on a 0-10 pain scale.”

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‘High Impact Chronic Pain’ (HICP)

• 2011 IOM report: 40% US adults have chronic pain

• Chronic pain defined only by duration of pain

• Two recent studies on HICP: How often do you have pain and how often did pain limit your work or life activities?

• 20% US adults have chronic pain

• 8% have HICP, with increase prevalence with advancing age

Dahlhamer, Morbidity and Mortality Weekly, 2018

Pitcher, The Journal of Pain, 2018

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‘High Impact Chronic Pain’ (HICP)

• The definition, the language, impact the research and treatment approaches

• Brings function and quality of life into the discussion

• Shifts the focus to active care

• Changes treatment focus from pain management to life management

• Treatment example: CBT and graduated activity

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Parsing and Treatingright patient, right provider, right time

PCP • Red Flags:

– if + refer condition as always…– but no red flags, no imaging

• Yellow flags – (psychosocial tool): if + refer to spine program

• Focused and meaningful history/exam• If + for neuro or leg/arm pain, refer to pathway

trained spine provider• If all the above negative: exercise, NSAIDS/ACET?

and keep active

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Cochrane: >2500 Controlled Trials, 32 Systematic Reviews - Chou R, et al. Diagnosis and

treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007

Strong Evidence Fair Evidence

Acute LBP • Early gradual activity• Discourage bed rest• Recognize psychosocial factors

• Pharmaceuticals• Manipulation

Chronic LBP • Supervised exercise• Cognitive behavioral therapy• Multidisciplinary treatment

• Pharmaceuticals• Manipulation

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Worth mentioning: Motivational Interviewing and Cognitive Behavioral Therapy

• Key is to contextualize care pathway to the patient through the principles of MI and CBT

• Peer conversation• Compassionate and accepting dialogue• Evoke from the patient skills they already

possess • Ask the patient to tell you what the benefits

of the change would be

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Worth mentioning: Radiculopathy: Recommended Treatment

Acute: NSAID, Oral steroid, ESI

Chronic: Neural mobilization

7474

Bruegger’s Stretch

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The “Social”

• Job satisfaction

• Home life

• Social interaction

• Relationships

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Worth Mentioning: Essential Messages for Everyone

• Overcoming vs getting rid of; manage vs cure

• Activity is good

• Avoiding activity that is detrimental

• LBP is a very painful inconvenience that nearly everyone can overcome

• Initial visit therapy is an active therapy so that pt’s first experience of relief is something that they do

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Pain Self-Management Strategies

• Ease Tension

• Pace Activities

• Use Medications Appropriately

• Improve Mood

• Think Constructively

• Socialize/Recreate

• Shift Focus

• Improve Sleep

• Move/Exercise

• Use Good Ergonomics

Consume Wisely, UC Davis Medical Center

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Worth Mentioning: High patient satisfaction when you:

• Palpate area of pain (touch the patient)

• Give a diagnosis: ‘mechanical back pain’ is OK (better than ‘non-specific back pain’)

• Contextualize cognitive behavioral therapy (reassurance that: intense pain is usually short lived, that bad pain does not mean bad disease, rarely needs further testing, safe to move, we can help you)

• Education recommendations

• Referral is appropriate

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Primary Spine Practitioner - aka PSP (trusted non-surgical spine specialist)

• Degree Agnostic (MD,DO,DC,PT,NP, PA…):

• Assist in Coordination of Spine Related Care

• Evidence Based Approaches in Hx, Px, and Tx

• Accurate / Quick Triage for Imaging, Surgical and Pain Intervention Consults (‘Fast Track’)

• Emphasis on Self Directed Care

• Knowledge of manipulation and exercise, appropriate use of opioids and steroids, full spectrum Dx/Rx options to effectively and efficiently coordinate care

• Promote a Public Health Perspective for Spine Care

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– Red Flags

– Exam: Causal Mechanisms, Treatment Response

– Perpetuating Factors/Yellow Flags

-Stratified Care

– Refer to Fast Track as Spine Community has Agreed To

– Treat without Additional Referral ~ 70 - 80%

– Manage/Co-manage All Spine Cases (Musculoskeletal Only)

Primary Spine Practitioneraka PSP approach

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Algorithm for osteopathic manipulative treatment (OMT) for low back pain (LBP) decision

making.

. J Am Osteopath Assoc 2010;110:653-666

Core Components of Spine Health Program

Process

Team of Providers

Primary Care Providers (PCP)

Primary SpinePractitioner

(PSP)

High Performing Network (HPN)

1. Systematicdiagnosis and outcomes tracking

➢ Empoweringlanguage

➢ No Red Flags, no imaging

➢ Risk severity measure

➢ Motivationalinterviewing with psycho social screening

➢ “Multidisciplinary” exam

➢ Patient directed outcomes

➢ “Fast Track”criteria

➢ Consultation and communication on difficult cases

2. Pathway Guided Stepped Care

➢ Treat low complexity

➢ Emphasize patient active care

➢ Pathway based referrals

➢ Minimally invasive, patient active care plan

➢ Modify per psychosocial screening

➢ Modify treatment if no/slow improvement (~2 weeks)

➢ Patients not improving or “flagged” getting quick referral

➢ Testing, treatment, referral according to evidence-based pathway

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HIGHPERFORMING

NETWORK/“Fast Track”

OTHER SPINE SPECIALIST

URGENT CARE

Physiatry /Rehab

PRIMARY CARE

SPINESURGEON

PSYCHO-LOGIST

PRIMARY SPINEPRACTITIONER

PAIN INTERVEN-

TIONIST

NEUROLOGIST

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Enhanced Relationships and Momentum

• Primary Care Practitioners (PCPs)

– Satisfied patients

– More PCP choice (off load to “extender”)

– Less PCP work (simple pathway)

– Time to focus on clinical strengths

• Specialists

– More appropriate case mix

• Primary Spine Practitioners (PSPs)

– Integration

– Exposure (new patient volume)

– Goal: value based reimbursement

• Employers

– Direct costs

– Productivity and indirect costs

• Communities

– Culture change

– Common language

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Primary Care Physician Comments

• The spine program has improved access to care, enhanced the quality of evaluation and treatment, and markedly improved the patient care experience. At the same time, it's presence is reducing costs associated with high-priced specialty care and imaging while improving outcomes.

• It has made my work of caring for those with neck and back pain much simpler and more satisfying.

- Robert Cole, MD, Medical Director, LHMG

• “My patients have found our spine program to be very helpful. They have been surprised by the thoroughness and completeness of the evaluations and treatment recommendations they have received.”

• “Our two PSP’s are very willing to work with us as partners in the treatment of our patients.”

- Mark Cohen, MD, Associate Medical Director, LHMG

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90 minutes can make a big difference!

A short training, a PSP infrastructure, some big savings

and a journal submission

“pilot achieved a 28 percent reduction in

costs for the treatment of back pain in 12

months. The control group actually saw an

8 percent increase in costs”

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Consumer Reports - June 2017

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a pilot program run byExcellus BlueCross BlueShield found thateducating doctors about a restrainedapproach to back pain was paying offfor patients and the bottom line. “Imaging, visits to specialists or the emergency room, surgery, opioid prescribing, and costs all decreased, while patient satisfaction went up.”

Project ECHO ™ ~ Extension for Community Healthcare Outcomes

• Lifelong learning model developed at U. New Mexico (Hep C)

• The heart of the ECHO model™ is its hub-and-spoke knowledge-sharing networks, led by expert teams who use multi-point video-conferencing to conduct virtual clinics with community providers

• By putting local clinicians together with specialist teams in virtual clinics, Project ECHO shares knowledge and expands treatment capacity

• The result: better care for more people

• Excellus BCBS – first insurer to co-ordinate and host an ECHO (MAT)

• Engage community partners

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The Spine Health Program: Springboard to Wellness?Reproducible Pathway Model?

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Engaging Patients in the Decision

Do I Need an MRI Scan? • Usually not recommended Within the First Six Weeks

• Abnormalities shown on the MRI scan are often not actually be the cause of back pain.

• Numerous studies have shown that approximately 30% of people in their thirties and

forties have a lumbar disc herniation on their MRI scan, although they do not have any

back pain. There are many such normal findings that can sound scary.

Indications for when to get an MRI scan include:

• After 4 to 6 weeks of leg pain, if the pain is severe enough to warrant surgery

• After 3 to 6 months of back pain, if the pain is severe enough to warrant surgery

• If the back pain is accompanied by constitutional symptoms (such as loss of

appetite, weight loss, fever, chills, shakes, or severe pain when at rest) that may

indicate that the pain is due to a tumor or an infection

• Persistent unrelenting back pain not changed by body position. (No position

makes it better or worse)

• For patients who may have spinal stenosis and are considering an epidural

injection to alleviate pain

• For patients who have not done well after having back surgery, specifically if

their pain does not improve after 4 to 6 weeks.

Another important consideration with MRI scans is the timing of when the scan is done.

The only time an MRI scan is needed immediately is when a patient has either:

• Bowel or bladder incontinence

• Progressive weakness in the legs due to nerve damage.

Early and inappropriate ordering of MRI scans can prolong your recovery by common

misinterpreatation of normal findings, driving needless clinical testing and possibly

unnecessary treatment that have inherent risks.

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Consumerism and the Amazon Effect:Judging Practitioners

Quality Data / Cost Data

….and this is good for quality practitioners

Opinion and anecdote (How many stars?)

….risky and possibly misleading

Best if consumer information has meaningful data agreed upon by patients, providers and payers

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Spine Health Program Overview

• Better Outcomes

• Happy Patients

• Less Cost

• Less PCP work (simple pathway)

• More PCP choice (off load to “extender”)

• The importance of “first touch”

• Changing the ‘culture’ of spine care

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Should Kansas BCBS Implement a Spine Health Program?

• Interest in the Spine Care Pathway

• Voluntary pathway training

• Tool and best practice sharing

• Data share (registry?)

• Team development

• Patient education tools

• Aligned incentives (patients and providers)

• Reimbursement incentive (QBRP for Data Registry, 28 day LBP X-ray HEDIS Measure )

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Thoughts?

Questions?

brian.justice@excellus.com

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